Is a small brown eschar in the center of a healing second-degree burn normal?

Brown Eschar in Healing Second-Degree Burns: Assessment and Management

A small brown hardened eschar (necrotic tissue) in the center of a healing second-degree burn requires careful assessment but may represent normal healing if the surrounding tissue shows signs of re-epithelialization and there are no signs of infection.

Understanding Eschar Formation in Second-Degree Burns

Eschar is dead tissue that forms over burn wounds and is specific to burn injuries, requiring a different treatment approach than other traumatic wounds 1. In second-degree burns:

• The presence of eschar indicates areas of deeper tissue destruction that may need debridement 1
• Brown or black hardened debris represents necrotic tissue that can harbor bacteria beneath its surface, even when the wound appears to be healing around it 1, 2
• The subeschar plane (area beneath the eschar) can harbor microorganisms that topical antimicrobials cannot reach, as many agents cannot penetrate through the hardened eschar 1

When Brown Eschar is Concerning vs. Normal

Signs That Require Immediate Medical Evaluation:

• Spreading redness, warmth, or swelling around the eschar (indicating cellulitis or invasive infection) 3, 2
• Systemic signs of infection such as fever, chills, or malaise 3, 2
• Increasing pain or foul odor from the wound 2
• Purulent drainage or changes in wound appearance suggesting deeper infection 3
• Burns involving the face, hands, feet, or genitals should be evaluated by a burn specialist regardless of eschar presence 4, 3

Signs of Normal Healing:

• Small, stable eschar with healthy pink tissue re-epithelializing around the edges 4
• No signs of spreading infection or systemic symptoms 3
• Decreasing rather than increasing pain 4

Management Algorithm

Step 1: Assess for Infection

• Look for signs of invasive infection (spreading cellulitis, systemic symptoms, purulent drainage) 3, 2
• If infection is present, systemic antibiotics are indicated targeting both Gram-positive (especially Staphylococcus aureus) and Gram-negative bacteria 3

Step 2: Determine Need for Debridement

• Surgical debridement of necrotic tissue decreases bacterial burden and prevents invasive burn wound infection 3
• For small second-degree burns being managed at home without signs of infection, the eschar may separate naturally as the wound heals 4, 1
• Do not attempt to forcibly remove eschar at home without medical guidance 5

Step 3: Wound Care Protocol

• Clean the wound with tap water or isotonic saline before applying dressings 3
• After cooling and cleaning, apply petrolatum-based antibiotic ointment, honey, or aloe vera with a clean nonadherent dressing for small partial-thickness burns 4, 3
• Change dressings regularly and monitor for signs of infection 3

Step 4: Seek Specialist Consultation If:

• The burn involves >10% body surface area (5% in children) 4
• The burn involves face, hands, feet, or genitals 4, 3
• Signs of infection develop 3, 2
• The eschar is enlarging or the wound is not showing signs of healing 2

Critical Pitfalls to Avoid

• Do not use routine prophylactic systemic antibiotics, as they may select for multidrug-resistant bacteria without clear benefit 3
• Do not irrigate wounds under pressure, as this spreads bacteria into deeper tissue layers 5
• Do not squeeze or manipulate the eschar, especially if infection is suspected 5
• Do not assume the wound is superficial based solely on what is visible; eschar can obscure deeper tissue destruction 6, 1

Pain Management

• Over-the-counter analgesics such as acetaminophen or NSAIDs are appropriate for burn pain control 4, 3

Bottom Line

For a small second-degree burn healing at home with a small brown eschar in the center: this may be normal if there are no signs of infection and the surrounding tissue is re-epithelializing 4, 1. However, if there are any signs of spreading infection, systemic symptoms, or if the burn involves critical areas (face, hands, feet, genitals), immediate medical evaluation is required 4, 3, 2. When in doubt, seek evaluation by a healthcare professional or burn specialist, as burn wounds have unique characteristics that differ from other traumatic wounds and require specialized assessment 1, 2.